Conventional Evaluation and Treatment of Burning Mouth Syndrome

By Susan E. Sklar, M.D.

The first step in treating Burning Mouth Syndrome is a thorough evaluation. A physician must make the diagnosis initially. This because there are other diseases and side effects of medicines that can occur with similar symptoms.

Do you have Burning Mouth Syndrome?

Are you plagued with burning in your mouth or tongue?  Does it occur every day?  Has it gone on for four to six months?  Have you been to many doctors and dentists who say everything looks normal?  If so, you likely have Burning Mouth Syndrome.

Sklar Center treats Burning Mouth Syndrome

Burning Mouth Syndrome is a chronic pain condition. It is a neuropathy. This means that a nerve becomes inflamed and sends messages to the brain that something is wrong. This shows up as either burning pain, tingling, a metallic taste in the mouth or a feeling of dry mouth.

Patients end up seeing a wide variety of healthcare practitioners before they receive a diagnosis.  The patients we see it the Sklar Center have often seen a dentist, ear nose and throat doctor, oral surgeon, allergist, primary care doctor, neurologist, rheumatologist and sometimes an infectious disease doctor. Very few doctors have heard of Burning Mouth Syndrome. And fewer doctors know how to treat Burning Mouth Syndrome.  This fact makes it much more difficult for patients. Estimates show that it takes two to three years to make the diagnosis. Moreover, before patients learn the diagnosis, they have seen an average of four to five doctors.

Who Gets Burning Mouth Syndrome?

Burning Mouth Syndrome mainly affects women, particularly after the menopause. The highest numbers are in women aged 60 to 69.  90% of the people who have Burning Mouth Syndrome are perimenopausal or menopausal women. This shows a high likelihood that hormones play a role.  Men who experience burning sensations in their mouths are affected far less than women, 1/3 to 1/10 as often. The average age for Burning Mouth Syndrome in females is 64.  For men, it is older.  It is rare to find burning mouth syndrome in females under age 30 and in males under age 40.

What Causes Burning in the Mouth?

There are many conditions which can cause burning in the mouth. A physician must make a thorough evaluation before making the diagnosis of Burning Mouth Syndrome. Some of the causes are what a follows:

Medications can be the cause 

The first thing to look at is current medications. Medications can cause the following symptoms: burning in the mouth, low saliva levels, and dry mouth.

The most implicated medications are high blood pressure medications principally those that act on the renin-angiotensin system. These include captopril, enalapril and lisinopril.

Nutritional Deficiencies can cause Burning Mouth

Certain vitamin and mineral deficiencies can cause neurologic problems like Burning Mouth Syndrome.

Hormone Deficiencies can be a cause

90% of the patients with Burning Mouth Syndrome are peri-menopausal and menopausal women.  Multiple hormone deficiencies occur at this time of life.

Thrush is a yeast infection

A yeast infection from Candida on the tongue can cause burning.  Usually the tongue is coated white or gray.  One study showed that treatment with a topical antifungal medication in the mouth helped 2/3 of the subjects in the study.

Diabetes and other causes of nerve dysfunction and disease called neuropathy can be a cause

Diabetics are known to have increased risk of neuropathy with burning in the legs and feet. They also have increased risk of Burning Mouth Syndrome.

Viral Infections may be involved

Many viral infections cause blisters in the mouth which can leave pain after healing.  It is important to note that these viral infections can cause pain even if blisters are not present.[4] Here is a list of viral infections that can cause pain.

Autoimmune Disorders also cause pain

Autoimmune disorders are diseases where the body attacks its own tissues. These diseases can cause similar symptoms to Burning Mouth Syndrome.  Autoimmune diseases can cause dry mouth, pain, and burning in the mouth.

Mast Cell Activation Syndrome is another cause

Immune cells called mast cells become active during allergic reactions normally.  When they are overactive, Burning Mouth can result.

Gastro-esophageal reflux/laryngeal-pharyngeal reflux is common

This is a disease caused by loosening of the lower esophageal sphincter. This allows reflux of gastric contents into the esophagus, throat  and mouth, causing burning pain.

What is the Evaluation for Burning Mouth Syndrome?

Initially, a physician examines the mouth and tongue.

  • Is there a white coating
  • Are there tiny blisters
  • Are there white patches
  • Is there low salivary flow?

Laboratory testing:

  • Cultures (swab tests) for herpes and other viral infections as well as a culture for yeast infection.
  • Blood tests for vitamin and mineral status.

Vitamin B2, B6, B12 and folate. red blood cell magnesium, iron, total iron binding capacity, percent saturation, and ferritin levels

  • Blood tests can show prior viral infection which may still be lurking in the nerve roots and causing pain.
  • Blood test for autoimmune diseases.

It’s Not in Your Head:

Burning Mouth Syndrome is a central neuropathic pain condition.  This means that the nerves connecting your tongue sensations to your brain are not functioning correctly. It also means that the problem is in your brain cells as well as the nerves to your tongue and mouth.  No one knows exactly why this happens.

Making a diagnosis can be difficult

Usually, the biopsy looks normal. However, special stains show an overall reduction in nerve fibers in the lining of the mouth of Burning Mouth Syndrome patients. This is compared to people who don’t have Burning Mouth Syndrome. Also, there is degeneration of the long, thin connector nerves called the axons. In addition, certain pain receptors and nerve growth factors were different in the tongues of Burning Mouth patients from healthy subjects. There are differences in proteins that are involved in pain feelings between Burning Mouth patients and controls. These studies show that there is a factual basis for the dysfunction of nerves in Burning Mouth Syndrome.  You are not imagining it!

There are differences in brain function

There are also differences in the brains of Burning Mouth sufferers. They have lower dopamine. Dopamine is a pain modulating brain chemical.  This could also be a contributor to the chronic pain in Burning Mouth Syndrome.

There are theories about the cause of Burning Mouth Syndrome

Hormones as a cause 

There are several theories about the cause of Burning Mouth Syndrome.  Since 90% of the people who have this condition are peri-menopausal and menopausal women, hormone decline is one possible cause.  We also know that stress and anxiety are associated with worse pain in Burning Mouth Syndrome.  Doctors used to think it was “all in the head.”  However, we know that there are many physiological changes that increase pain when there is emotional stress.

Mast Cell Activation

Another theory is mast cell activation. This is a condition where a type of white blood cell called mast cells release irritating and inflammatory chemicals that cause nerve pain.

Lack of Neuroactive Chemicals

What we do know about neuropathic pain is that they persist because there are not enough nourishing chemicals for nerve growth and repair.  In addition, the researchers find that the nerves are inflamed.  This adds up to pain, burning, taste abnormalities, and feelings of dryness.

What are the Standard Treatments for Burning Mouth Syndrome?

There are many treatments for Burning Mouth Syndrome.  Here are the most prescribed medications in traditional medical treatment.

  • Topical Capsaicin (hot peppers) can be a help
  • Topical Clonazepam can be effective
  • Topical Mouth Moisturizers are used
  • Anti-depressant medications show modest benefits
  • Anti-seizure medications have significant side effects
  • There are supplements for the treatment of Burning Mouth Syndrome
  • Low Level Laser treatments need more study
  • Cognitive Behavioral Therapy can be helpful

And it’s NOT in your head.

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